Immediate Treatment for All of Us? PrEP for Everyone Else?

Immediate Treatment for All of Us PLWHA?

Another National HIV Testing Day, June 27, is just around the corner! Another is a bittersweet word. We're still here, but so is the HIV epidemic, after thirty years. But at least advances in treatment are changing the terms of HIV policy debate.

Remember the eighties, when we didn't start taking HIV antiviral drugs until we absolutely had to, because there was only AZT, it didn't keep working very long, and it was toxic?

Then the drugs got more effective and caused fewer side effects. The debate recently has been whether to start treatment when a patient's T cell count falls below 350 or earlier, at 500. A growing majority of medical opinion supports starting at 500, and some doctors even say, never mind T cell counts, start treatment as soon as the patient is diagnosed. Patients who start treatment earlier do better in the long term.

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The observation that people in treatment with undetectable viral load are also much less likely to pass HIV on to others has started another debate: can we test-and-treat our way out of the epidemic? If everyone who has HIV is in treatment, will new infections become a rarity?

Some think not, but it's never really been tried in a whole population. British Columbia is trying test-and-treat for all in its East Vancouver HIV hot spot of injection drug users, and, lo and behold, community viral load and the rate of new infections are both dropping. The concept seems to work. British Columbia's policy of treating injection drug use as a public health issue, not a crime, is also reducing the other harms that drug use causes. With supervised shooting-up sites and a guaranteed supply of clean needles, overdose deaths are down, and transmission by needle of HIV and other blood-borne diseases is almost certainly down as well. (Click HERE to read more about possible lessons to be learned from British Columbia's experiment with treatment for all.)

Can the British Columbia results be reproduced in untidy U.S. cities without a single-payer healthcare system? San Francisco is set to find out. The San Francisco Chronicle reports the city's new treatment guidelines for PLWHA in its hot spot, gay men: immediate treatment upon diagnosis, with a projected resulting 60% drop in new MSM infections over eight years. With universal, frequent testing for gay men, new infections could drop by as much as 80%.

If San Francisco can make this work, the public healthcare cost savings will be huge -- and demonstrable. It will permanently change the terms of state and Federal HIV program budget debates until the day we have a vaccine and a cure.

It will also demonstrate once and for all that HIV is a disease of broken healthcare systems. Reach everyone with prevention, testing, and immediate treatment, and HIV will become a memory. Leave the healthcare system the way it is, and HIV will be with us forever.

PrEP for Everyone Else?

Pre-exposure prophylaxis -- PrEP -- has generated a lot of recent debate. Can we reduce the number of new infections by giving HIV-negative people at high risk of becoming infected the same drugs that control (but don't cure) the virus in PLWHA?

Is it even a good idea? There are strong arguments on both sides. Some think PrEP could actually increase transmission in gay men, by letting them think they can stop using condoms. That's a valid concern, but there's a lot of unprotected sex happening already, and we shouldn't let concerns about the behavior of gay men in developed countries keep us from developing workable PrEP for groups that have few other options for protecting themselves -- sex workers, and third-world women in general, who too often have no control over their own sexual lives or the behavior of their male partners.

So we said "Ouch," last week, when some HIV advocates actually celebrated the early termination of the FEM-PrEX trial of oral Truvada for prevention in heterosexual women. It could not be shown that PrEP using Truvada was as effective in women as it has been shown to be in men. The results were puzzling: why should oral PrEP work better in MSM than in women? And disappointing: it's women who most need PrEP to work.

We think there are real problems with PrEP. The drugs are expensive. Successful prevention depends on near-perfect compliance with a regimen of daily pills -- easier for those of us who know that without them we will progress to full-blown AIDS than for uninfected people who may think they can skip a dose now and then. And even the latest generation of drugs has side effects -- not as serious as in the early days, and the benefits certainly outweigh the risks for those of us who are already positive. But can we justify causing those side effects in people who are not infected? And there's a whopping ethical problem in prescribing ART drugs to uninfected people who have insurance and can pay for them, but not to the uninfected poor, and not to lower-income infected Americans on ADAP waiting lists. We need to find a better way -- cheaper, universally available, less compliance-dependent prevention interventions, which we think may eventually come in the form of periodic boosting of uninfected people's immune systems.

That's a hope that will only come true after years of research. The attraction of PrEP using antiviral drugs is that the drugs are available now. When your house is on fire, you don't stop working to develop better fire hoses, but you also use the hose you have today. We're sorry the FEM-PrEP trial didn't have the results we hoped for, and we trust and pray that researchers will find ways to make oral PrEP work for women.

Peter Kronenberg is the vice president for communications for the National Association of People with AIDS. First published in NAPWA Positive Voice4/25/2011.

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